Because the NHS was founded to provide equal access to all on the basis of need rather than the ability to pay, price was eliminated as a method of bringing demand for services into line with supply. This means that the Government has to make decisions about the amount of health care they are prepared to fund, and there will always be a gap between supply and demand. Managing scarcity is the most important task facing the NHS, and the ability to manage it will determine its future. The authors argue that the initial settlement made between the state and the medical profession when the NHS was founded is changing and must change further. Any fundamental change within the NHS requires an adjustment to the NHS's implicit constitution, that is the balance of power between professionals, the state and the public, and this must start with the political role.